Online Intake FormLast Name First Name Middle Initial Gender MaleFemaleBirth Date Age Marital Status MarriedDivorcedSeparatedSingleOtherAddress City Zip Code County State Home Phone Insurance Provider Veteran Service Education Grade 12 or GEDCollege4 Year UniversityTrade SchoolOtherDo you have any Allergies? NoYesIf "yes" please describe Background InformationCONTACT PERSON INFORMATIONContact Person Contact Person’s Phone # Relationship Address City/State/Zip Telephone Home Other DRUG OF CHOICE1st Preference AlcoholHeroinPrescription NarcoticsCocaineCrack CocaineBenzodiazepinesMarijuanaAmphetamineAge of 1st use Last date of use 2nd Preference AlcoholHeroinPrescription NarcoticsCocaineCrack CocaineBenzodiazepinesMarijuanaAmphetamineNoneOtherAge of 2nd use Last date of use 3rd Preference AlcoholHeroinPrescription NarcoticsCocaineCrack CocaineBenzodiazepinesMarijuanaAmphetamineNoneOtherAge of 3rd use Last date of use Number of prior treatments: Number of prior treatment at QBH: Have you had legal issues? YesNoIf you selected "Other" for any of the above choices, please provide drug type here:Notes/Comments:
